Resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjunct treatment in life threatening postpartum hemorrhage: Fourteen years' experience from a single Norwegian center.

INTRODUCTION: Postpartum hemorrhage (PPH) remains a global health problem. The introduction of resuscitative endovascular balloon occlusion of the aorta (REBOA) in 2008 sought to enhance the management of hemorrhagic shock during PPH. In this study, we present a single Norwegian center's experience with REBOA as a supportive treatment in combating life threatening PPH. MATERIAL AND METHODS: This is a historical cohort study from St Olav's University Hospital, with data from period 2008-2021. It includes all patients who underwent REBOA as an adjunct treatment due to life threatening PPH, analyzing the outcomes and trends over a 14-year period. RESULTS: A total of 37 patients received REBOA as an adjunct treatment. All procedures were technically successful, achieving hemodynamic stability with an immediate average increase in systolic blood pressure of 36 ± 22 mmHg upon initial balloon inflation. Additionally, a downward trend was noted in the frequency of hysterectomies and the volume of blood transfusions required over time. No thromboembolic complications were observed. CONCLUSIONS: Our 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life-threatening PPH. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review.

BACKGROUND: Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS: This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS: Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION: A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Transfusion practice in Central Norway - a regional cohort study in patients suffering from major haemorrhage.

BACKGROUND: In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. METHODS: In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. RESULTS: A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. CONCLUSIONS: Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.

Posttraumatic Stress Responses and Psychological Well-being in Norwegian Medical Helicopter Personnel.

OBJECTIVE: Emergency medical personnel are exposed to multiple stressors, including those of psychological etiologies. The aim of this study was to report the prevalence of anxiety, depression, and posttraumatic stress symptoms in Norwegian medical helicopter personnel and to determine to what degree they report personal growth or deprecation due to exposure to work-related events. METHODS: This was a web-based, cross-sectional survey performed among rescue paramedics and physicians staffing helicopter emergency medical services and search and rescue helicopters between May 5, 2021, and July 5, 2021. Questions included demographic data, the traumatic events exposure index, the Generalized Anxiety Disorder 7 scale, the Patient Health Questionnaire 9 (Depression), the posttraumatic change scale, and the posttraumatic symptom scale. RESULTS: Of the 245 eligible participants, 10 declined to take part and 74 failed to answer, producing a response rate of 66% (72 rescue paramedics and 89 physicians). Of the study population, 3.9 % reported manifest posttraumatic stress disorder symptoms, and 1.9% described moderate to severe depression and anxiety. The majority (76%) described posttraumatic emotional growth because of their work experience. CONCLUSION: Despite exposure to several traumatic stressors, participants reported a lower prevalence of posttraumatic stress symptoms, depression, and anxiety compared with a Norwegian adult population.

Improper monitoring and deviations from physiologic treatment goals in patients with brain injury in the early phases of emergency care.

Severe traumatic brain injury (TBI), out-of-hospital cardiac arrest (OHCA) and intracerebral- and subarachnoid hemorrhage (ICH/SAH) are conditions associated with high mortality and morbidity. The aim of this study was to investigate the feasibility of obtaining continuous physiologic data and to identify possible harmful physiological deviations in these patients, in the early phases of emergency care. Patients with ICH/SAH, OHCA and severe TBI treated by the Physician-staffed Emergency Medical Service (P-EMS) between September and December 2016 were included. Physiological data were obtained from site of injury/illness, during transport, in the emergency department (ED) and until 3 h after admittance to the intensive care unit. Physiological deviations were based on predefined target values within each 5-min interval. 13 patients were included in the study, of which 38% survived. All patients experienced one or more episodes of hypoxia, 38% experienced episodes of hypercapnia and 46% experienced episodes of hypotension. The mean proportion of time without any monitoring in the pre-hospital phase was 29%, 47% and 56% for SpO2, end-tidal CO2 and systolic blood pressure, respectively. For the ED these proportions were 57%, 71% and 56%, respectively. Continuous physiological data was not possible to obtain in this study of critically ill and injured patients with brain injury. The patients had frequent deviations in blood pressure, SpO2 and end tidal CO2-levels, and measurements were frequently missing. There is a potential for improved monitoring as a tool for quality improvement in pre-hospital critical care.

A prospective observational study comparing two supraglottic airway devices in out-of-hospital cardiac arrest.

BACKGROUND: Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion. METHODS: All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD's. RESULTS: Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients. CONCLUSIONS: Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.

Developing Quality Indicators for Helicopter Emergency Medical Services Coordination in Norwegian Emergency Medical Communication Centrals: A Consensus Process.

OBJECTIVE: Efforts to optimize the use, availability, and safety of helicopter emergency medical services (HEMS) is important. A lack of consistent and comprehensive flight dispatch procedures and a lack of use of safety technology are recurring safety problems. Reports after several major incidents pointed toward a possible gain by coordinating Norwegian HEMS from regional emergency medical communication centrals. Our objective was to develop and implement relevant quality indicators before such implementation in central Norway. METHODS: We recruited an expert panel of 24 persons representing Norwegian health authorities, emergency medical communication centrals, and HEMS bases and performed a 3-step e-mail-based Delphi process to develop relevant quality indicators. Each indicator was assessed according to their feasibility, rankability, actionability, and variability. To reach a consensus, a median score of 5 or more on a 6-point Likert scale in step 3 was needed. RESULTS: A total of 61 quality indicators were proposed. Of the 14 indicators that reached a consensus, 12 of these were considered process indicators, and 2 were bordering to outcome indicators. CONCLUSION: We applied a Delphi process method to develop quality indicators for HEMS coordination and flight following. An experienced and heterogeneous expert panel suggested and reached a consensus on which quality indicators should be applied.

Prehospital Stressors: A Cross-sectional Study of Norwegian Helicopter Emergency Medical Physicians.

OBJECTIVE: Personnel working in helicopter emergency medical services (HEMS) and search and rescue (SAR) are exposed to environmental stressors, which may impair performance. The aim of this survey was to study the extent HEMS and SAR physicians report the influence of specific danger-based and non-danger-based stressors. METHODS: The study was performed as a cross-sectional, anonymous, Web-based (Questback AS, Bogstadveien 54, 0366 Oslo, Norway) survey of Norwegian HEMS and SAR physicians between December 2, 2019, and February 25, 2020. RESULTS: Of the recipients, 119 (79.3%) responded. In helicopter operations, 33.6% (n = 40) reported involvement in a minor accident and 44.5% (n = 53) a near accident. In the rapid response car, 26.1% (n = 31) reported near accidents, whereas 26.9% (32) reported this in an ambulance. Of physicians, 20.2% (n = 24) received verbal abuse or threats during the last 12 months. When on call, 50.4% (n = 60) of physicians reported sometimes or often being influenced by fatigue. CONCLUSION: This study shows that Norwegian HEMS and SAR physicians are exposed to several stressors of both a danger-based and non-danger-based nature, especially regarding accidents, threatening patient behavior, and fatigue. Very serious incidents appear to be seldom, and job satisfaction is high.

Quality measurement in physician-staffed emergency medical services: a systematic literature review.

PURPOSE: Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. DATA SOURCES: The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. STUDY SELECTION: The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. DATA EXTRACTION: The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. RESULTS OF DATA SYNTHESIS: In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'. CONCLUSION: The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Real-time forecasting of emergency department arrivals using prehospital data.

BACKGROUND: Crowding in emergency departments (EDs) is a challenge globally. To counteract crowding in day-to-day operations, better tools to improve monitoring of the patient flow in the ED is needed. The objective of this study was the development of a continuously updated monitoring system to forecast emergency department (ED) arrivals on a short time-horizon incorporating data from prehospital services. METHODS: Time of notification and ED arrival was obtained for all 191,939 arrivals at the ED of a Norwegian university hospital from 2010 to 2018. An arrival notification was an automatically captured time stamp which indicated the first time the ED was notified of an arriving patient, typically by a call from an ambulance to the emergency service communication center. A Poisson time-series regression model for forecasting the number of arrivals on a 1-, 2- and 3-h horizon with continuous weekly and yearly cyclic effects was implemented. We incorporated time of arrival notification by modelling time to arrival as a time varying hazard function. We validated the model on the last full year of data. RESULTS: In our data, 20% of the arrivals had been notified more than 1 hour prior to arrival. By incorporating time of notification into the forecasting model, we saw a substantial improvement in forecasting accuracy, especially on a one-hour horizon. In terms of mean absolute prediction error, we observed around a six percentage-point decrease compared to a simplified prediction model. The increase in accuracy was particularly large for periods with large inflow. CONCLUSIONS: The proposed model shows increased predictability in ED patient inflow when incorporating data on patient notifications. This approach to forecasting arrivals can be a valuable tool for logistic, decision making and ED resource management.

Search and Rescue and Remote Medical Evacuation in a Norwegian Setting: Comparison of Two Systems.

INTRODUCTION: Helicopter emergency medical services (HEMS) contribute to and complement other specialized search and rescue (SAR) services. Conversely, traditional SAR services perform medical evacuation (medevac), depending on crew, training, medical equipment, and procedures for interdisciplinary cooperation. We aim to describe and compare SAR and remote medevac mission characteristics in a military SAR helicopter system to a civilian HEMS operating in the same region. METHODS: Retrospective, observational study of SAR and remote medevac missions performed at a Norwegian military SAR helicopter and civilian HEMS base in the 5-y period from January 1, 2013 to December 31, 2017. Descriptive statistics and median values with interquartile range (IQR) were applied where appropriate. Comparisons were performed with the Mann-Whitney U test. RESULTS: We included 721 missions. The SAR service performed 359 (50%) missions, of which 237 (33%) were SAR and 122 (17%) were remote medevac missions. The HEMS service performed 85 (12%) SAR and 277 (38%) remote medevac missions. Median mission time for SAR missions was 152 (IQR 100-235) min for the SAR service and 57 (IQR 34-89) min for the HEMS service. Trauma was the dominating mechanism in 48% of patients, followed by medical conditions (21%) and psychiatric disorders (9%). Medevac patients in both services had a higher median National Advisory Committee for Aeronautics score of 3 (IQR 2-4) compared to 1 (IQR 0-3) in SAR missions (P<0.05). CONCLUSIONS: Both SAR and HEMS services perform SAR and remote medevac missions extensively and mission profiles vary.

Compliance With a National Standard by Norwegian Helicopter Emergency Physicians.

OBJECTIVE: The "National Standard Requirements for Helicopter Emergency Medicine Services Physicians" gives recommendations on medical requirements for flight physicians. This study describes the level of formal competence, experience, and guideline compliance of Norwegian helicopter emergency medical service (HEMS) physicians. METHODS: In May 2013, all HEMS physicians with full-time engagement at Norwegian HEMS bases were invited to participate in a cross-sectional survey using a structured, Web-based questionnaire. RESULTS: A total of 108 (79%) of 136 physicians replied to the survey, and all bases were represented. The majority (89%) had specialist training, and more than 60% had longer than 6 years of experience as a flight physician. Over 60% had attended trauma, pediatric, and incubator courses, and all physicians worked regularly in an anesthesia department. Most physicians were participating in simulation and procedure training. CONCLUSION: Many of the basic requirements of the guidelines were met by HEMS physicians, but room exists for improvements. Norwegian HEMS physicians are experienced, but a need exists for a more structured curriculum in emergency medicine for HEMS physicians based on the broad spectrum of presented medical conditions to ensure optimal quality of care and safety for all patients in Norway.

Injuries after violence and accidents - the forgotten pandemic? / Skader etter vold og ulykker ­ den glemte pandemi?

All information on injuries should be collected in a national injury registry devised for research. This will pave the way for a new strategy for injury prevention.

Helicopter emergency medical services response times in norway: do they matter?

OBJECTIVE: The main objective of the Norwegian air ambulance service is to provide advanced emergency medicine to critically ill or severely injured patients. The government has defined a time frame of 45 minutes as the goal within which 90% of the population should be reached. The aims of this study were to document accurate flying times for rotor wing units to the scene and to determine the rates of acute primary missions in Norway. METHODS: We analyzed operational data from every acute primary mission from all air ambulance bases in Norway in 2011, focusing on the flying time taken to reach scene, the municipality requesting the flight, and the severity score data. RESULTS: A total of 5,805 acute primary missions were completed in Norway in 2011. The median flying time was 19 minutes (25%-75% percentiles: 13-28). The mean mission rate for the 17 bases was 7.5 (95% confidence interval, 7.4-7.8 per 10,000 inhabitants). The overall mean (standard deviation) National Committee on Aeronautics score for all missions was 4.07 (1.30). CONCLUSION: The government's expectation of serving the entire population via HEMS within 45 minutes appears to be achieved on a national level. However, vast differences remain in the flying times and rates between bases.

Mortality rates in Norwegian HEMS-a retrospective analysis from Central Norway.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) provide rapid and specialized care to critically ill or injured patients. Norwegian HEMS in Central Norway serves an important role in pre-hospital emergency medical care. To grade the severity of patients, HEMS uses the National Advisory Committee for Aeronautics' (NACA) severity score. The objective of this study was to describe the short- and long term mortality overall and in each NACA-group for patients transported by HEMS Trondheim using linkage of HEMS and hospital data. METHODS: The study used a retrospective cohort design, aligning with the STROBE recommendations. Patient data from Trondheim HEMS between 01.01.2017 and 31.12.2019 was linked to mortality data from a hospital database and analyzed. Kaplan Meier plots and cumulative mortality rates were calculated for each NACA group at day one, day 30, and one year and three years after the incident. RESULTS: Trondheim HEMS responded to 2224 alarms in the included time period, with 1431 patients meeting inclusion criteria for the study. Overall mortality rates at respective time points were 10.1% at day one, 13.4% at 30 days, 18.5% at one year, and 22.3% at three years. The one-year cumulative mortality rates for each NACA group were as follows: 0% for NACA 1 and 2, 2.9% for NACA 3, 10.1% for NACA 4, 24.7% for NACA 5 and 49.5% for NACA 6. Statistical analysis with a global log-rank test indicated a significant difference in survival outcomes among the groups (p < 2⋅10- 16). CONCLUSION: Among patients transported by Trondheim HEMS, we observed an incremental rise in mortality rates with increasing NACA scores. The study further suggests that a one-year follow-up may be sufficient for future investigations into HEMS outcomes.

Patients' pathways to the emergency department: a scoping review.

BACKGROUND: Emergency department (ED) crowding is a common healthcare issue with multiple causes. One important knowledge area is understanding where patients arrived from and what care they received prior to ED admission. This information could be used to inform strategies to provide care for low acuity patients outside of the hospital and reduce unnecessary ED admissions. The aim of this scoping review was to provide a comprehensive overview of global published research examining the acute care trajectory of all ED patients. METHODS: The scoping review was performed according to the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive literature search was performed to identify studies describing where patients arrived from and/or whose pathway of care was before an ED visit. The search was conducted in MEDLINE, Embase, and the Cochrane Library from inception through December 5th, 2022. Two reviewers independently screened the records. RESULTS: Out of the 6,465 records screened, 14 studies from Australia, Canada, Haiti, Norway, Sweden, Switzerland, Belgium, Indonesia, and the UK met the inclusion criteria. Four studies reported on where patients physically arrived from, ten reported how patients were transported, six reported who referred them, and six reported whether medical care or advice was sought prior to visiting an ED. CONCLUSION: This scoping review revealed a lack of studies describing patients' pathways to the ED. However, studies from some countries indicate that a relatively large proportion of patients first seek care or guidance from a primary care physician (PCP) before visiting an ED. However, further research and published data are needed. To improve the situation, we recommend the development and implementation of a template for the uniform reporting of factors outside the ED, including where the patient journey began, which healthcare facilities they visited, who referred them to the ED, and how they arrived.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study.

BACKGROUND: Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times. OBJECTIVE: To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times. DESIGN: This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities. SETTING: Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022. MAIN OUTCOME MEASURES: Prevalence of busy ambulances and differences in response times associated with busy ambulances. RESULTS: The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively. CONCLUSION: Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.